Individual
TERRY SHAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
9196 W BARNES DR, BOISE, ID 83709-1552
(208) 433-0400
Mailing address
7239 W MODOC ST, BOISE, ID 83709-6158
(208) 954-7383
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
11416
ID
104100000X
Social Worker
Primary
33482
ID
Other
Enumeration date
02/11/2020
Last updated
02/11/2020
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